CDC Opioid Prescribing Guidelines Misguided, Docs Say

Brandon Cohen

Disclosures

April 08, 2016

How Did We Get in This Mess?

Recent guidelines handed down from the Centers for Disease Control and Prevention (CDC) concerning the prescription of opioids have made waves among healthcare professionals. The CDC condemned the practice of prescribing these drugs in the vast majority of cases. Furthermore, these guidelines characterized the widespread abuse of opioids as a "doctor-driven epidemic." A Medscape news article on this topic prompted fierce opposition from many healthcare professionals against what they saw as the uninformed overreach of a government agency.

The pushback began immediately. One physician turned the blame away from doctors and back on regulatory agencies:

The opioid epidemic was created by the government and the media under the direction of their bosses in the pharmaceutical companies. Physicians were demonized if they did not compassionately prescribe potent, newly branded extended-release opioids for chronic pain. Pharmaceuticals' profits soared and Americans got hopelessly addicted. Now the government says we physicians were to blame and need to immediately stop prescribing opioids to these addicted patients.

An orthopedic surgeon carried on the impassioned defense:

There is little doubt that the designation of pain [as the] "fifth vital sign" has ignited the notion that all pain is unnecessary and must be fully eradicated if we are to do our job correctly. This, coupled with short patient interactions, has created a real misconception of pain and its consequences.

An emergency department (ED) physician agreed and added, "This is not a doctor-driven epidemic. It is driven by [government health agencies] and patient satisfaction surveys."

Another ED physician continued the thread, citing personal experience and blaming Press Ganey (a provider of patient satisfaction surveys and doctor rating systems) as one of the prime causes of the epidemic of addiction:

Every day [I hear from patients,] "All they gave me was Advil®" over and over. You want to fix this: get rid of pain scores, stop telling me I'm undertreating pain, stop the easy route for complaints against us, get rid of Press-Ganey ... The pendulum swings. Soon we will be told we aren't writing enough again.

Another ED physician employed stinging sarcasm:

Great! The patient with chronic shoulder or back pain will be so happy when I tell him or her to try naproxen, acetaminophen, or ibuprofen—bet they hadn't thought of that. And then I will refer them to a cognitive-behavioral therapist who specializes in pain, which will hardly take any time out of their lives, will be convenient to get to, and will of course be covered so fully by their insurance. What's the [chance] they will be trying to get drugs on the street?

Concern for the Consequences

A pain management physician picked up on this idea and predicted dire consequences:

I see a huge chill on opiate prescribing followed by a massive increase in heroin deaths. Addiction care needs to be funded before the storm. Things are going to get way worse before they get better.

A colleague saw another potential danger:

[Have the government agencies] considered the number of patient suicides that have occurred as a result of unrelieved chronic pain? Get ready for a big increase, there cannot be a more tragic situation.

A registered nurse was clear and blunt:

Perhaps the government needs to look in the mirror before it blames providers for opioid addiction ... We all went to school for a long time and worked hard to get where we are. We should be allowed to make appropriate medical decisions without fear of administrative sanctions tied to satisfaction.

A retired orthopedic surgeon agreed, recalling years of practice:

It has been my clinical and personal experience that patients treated for true traumatic and post-surgical pain rarely, if ever, become dependent. I certainly saw my share of drug seekers, disability fraudsters, and street addicts who were not very difficult to recognize and were properly dealt with.

Another ED physician offered notes from the field:

Non-medical agencies have mandated pain scores from patients, and inevitably patients exaggerate their pain. Every shift, I have patients say their pain is a 10 while they are watching TV or texting on their phones .... Am I supposed to call them liars? .... What will their satisfaction scores then be with respect to how well their pain was managed?

A colleague recalled patients pointing to the pain scale sign in a treatment room and yelling, "This says I have a right to drugs!"

And a nurse offered powerful personal testimony suggesting that the CDC's recommendations were missing the real sources of addiction:

When my daughter became addicted to oxycontin at 16 years old, it was supplied by another 16-year-old who was stealing it from his grandmother with cancer. That was obviously not a doctor-driven issue. As an ED nurse, most of the overdoses that I see are not patients taking prescribed amounts, but diverted meds or [patients] taking way more than what was prescribed.

Is CDC on the Right Track?

A few voices supported the CDC's new guidelines. One physician proudly wrote:

Good to know I was right all along by denying patients opiates when other docs handed them out like candy—ridiculous! I've been cursed out by many opiate-addicted patients, but I stood my ground and I was right. I'm happy for this validation.

A pain management specialist saw much to criticize in the defensiveness of colleagues and implicitly buoyed the CDC's message:

The greatest disaster is that it seems too many primary care physicians (and nurse practitioners and physician assistants) really believe that they know more than they do about pain management ... I am plagued by referrals from individuals who send me their patients long after they have gone too far with opioid management.

The final word goes to a registered nurse who coupled work experience with personal anguish: "CDC, take my pain for a month; you would be on the streets trying to get your next fix. Let the doctors be doctors."

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